respectfully agree and disagree with this post responses and explain the reasoning :
In my opinion, J.T. is experiencing tolerance. Tolerance when related to a drug or medication is when the body gets so used to its effects that more medication is necessary to relieve the pain efficiently (Cai et al., 2022). There are neuron adjustments that occur from repeated exposure to these drugs that lessens the strength of the reaction the medication has on the body and its pain (Alegra et al., 2021). Dependence can occur from medications like morphine but not taking the medication would create more of a bodily response to the discontinuation of the medication itself rather than not feeling an effect from it like tolerance (Whalen, 2022, p. 328).
Since J.T. went into acute renal failure and was increasingly lethargic with confusion and hallucinations due to morphine metabolites, he needs to be switched to another medication. I do not believe haloperidol would be the best choice because he is not hallucinating coincidentally. He is hallucinating due to a metabolic disruption so there is potential for his hallucinations to get worse if the root cause is not addressed. Additionally, he is in pain, so if the morphine is discontinued and haloperidol is added, his pain management is not being addressed only his hallucinations (Woo & Robinson, 2020, p. 230). Decreasing the morphine would also not help because there is still a metabolite issue from taking that medication where it may not resolve his hallucinations and could cause an increase in his pain (Portenoy et al., 2023). One option that would normally be a great alternative would be hydromorphone because it is the preferred medication for patients that are experiencing any kind of kidney issues due to its lessened active metabolites (Whalen, 2022, p. 329). These metabolites are not lacking but they are much lower in intensity (Portenoy et al., 2023). Fentanyl patches are a great idea because they do not have active metabolites, so they are a better alternative for those with any renal issues (Portenoy et al., 2023). This drug is usually used more with patients with issues swallowing or if there is concern with absorption in the gastrointestinal tract (Portenoy et al., 2023). At this time, J.T. is lethargic so this is the best option in case he is having trouble swallowing with his lethargy. So, while inpatient, I would prescribe a transdermal fentanyl patch 50mcg to be applied every q72h and discontinue the morphine.
Someone taking opioids will not develop tolerances to adverse effects like respiratory depression, sedation, or nausea. In fact, they will start to develop a tolerance to the effects of the opioids, so they may take more of it which leaves them at a higher chance of deadly adverse reactions like respiratory depression and sedation (Alegra et al., 2021). The only adverse effect that comes from opioids that will not develop tolerance is constipation as eventually the constipation may subside after chronic opioid use (Lodhia et al., 2022)
B.
Relating to pain management, there is more that I need to understand about J.T to get the full picture and better understand his situation. One thing I would want to know is how long he has been on pain medications and which ones he has tried. Additionally, alternative measures to relieve pain need to be addressed. I would want to know if he has tried any topical pain relievers, see if there are any alternative therapies that he has tried or non-medical alternatives like ice, heat, exercise, stretching, massage, acupuncture, or yoga (Woo & Robinson, 2020, p. 1254).For example, if he wanted to try a transcutaneous electrical nerve stimulation device, that has been found to help with chronic pain and reduce the need for chronic pain medications (Johnson et al., 2022). Also, massage has been shown to cause immediate relief from pain caused by cancer (Gentile et al., 2018). If legal in his state, another alternative is medical cannabis as it has been found to help lessen opioid use for chronic pain or even eliminate the opioids all together (Bruce et al., 2018). On top of that, it was found that the medical cannabis alleviated symptoms faster when inhaled than taking oral opioids because inhalation helps get the cannabis absorbed into the blood stream at a quicker rate (Bruce et al., 2018). Luckily, there are several options as alternatives for helping with pain relief that may be able to lessen J.T.’s future opioid use.
Some things I would want to teach J.T. would be very well-defined instructions for how to use the opioids, when to use them and what adverse reactions could look like (Woo & Robinson, 2020, p. 266). Additionally, I would want to go over how long I would expect him to be on the medication and find some other alternative treatment to his medication that could be helpful (Woo & Robinson, 2020, p. 266). One other aspect is educating him what to look for regarding if the medication is working or if it has been ineffective as that will determine if a different medication or therapy needs to be used (Woo & Robinson, 2020, p. 266). It is especially important for him to know that there is a large risk of opioid dependence and why alternatives are so important (Tyson et al., 2021). Also, the opioids can cause dizziness or shorter reaction times so it should not be taken when operating a vehicle or something that involves alertness (Woo & Robinson, 2020, p. 266). And lastly, alcohol should be avoided with opioid intake as it can cause respiratory depression (Woo & Robinson, 2020, p. 266).
The DEA Drug Scheduling is a classification of narcotic drugs that is put in order of the dependency potential or how likely it is to be abused (DEA, 2023). The categories range from one to five with one being the most likely to be abused or cause a dependence and a category five has little potential for these issues (DEA, 2023). A schedule one drug is one that is not allowed to be prescribed and is usually found illegally like heroin or ecstasy (DEA, 2023). An example of a schedule five drug would be Robitussin because it contains only a small number of narcotics, so it is less likely to be addictive (DEA, 2023). In the case with J.T., the pain medications we were thinking about using with him are all schedule two medications (the fentanyl, hydromorphone, and methadone) (DEA, 2023).
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